Basic Information
| Provider Information | |||||||||
| NPI: | 1659578052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEETON | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 HERITAGE WAY | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062578992 | ||||||||
| FaxNumber: | 4067554161 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 HERITAGE WAY | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | KALISPELL | ||||||||
| State: | MT | ||||||||
| PostalCode: | 599013158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062578992 | ||||||||
| FaxNumber: | 4067554161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2007 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20385 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 20027 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 20385 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208000000X | 20385 | MS | N | Allopathic & Osteopathic Physicians | Pediatrics | 207RP1001X | 20027 | MT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 06386869 | 05 | MS | MEDICAID |